081 Vaccines and No Shows What the data shows with Chip Hart from PCC

As a dynamic and motivating speaker, Chip leads educational seminars and consults for pediatric professionals nationwide for organizations like the AAP, state chapter AAP programs, the MGMA, and various physician and hospital organizations nationwide. Chip was a member of the CCHIT Child Health Work Group and is a member of the CDC Clinical Decision Support and Children’s Model EHR Format working groups. Chip contributes articles on practice management and health care information technology for Pediatric Coding Alert, the AAP’s SOAPM Newsletter, Medical Group Management Association, The Independent Pediatrician,, and more. Chip lives in Vermont with his wife and their two sons.

This show was made possible by a generous corporate contribution from PBG. Physician Buying Group, helping pediatricians vaccinate children. And by Canid we partnered with them to offer you a free lunch where they'll help you understand the financials of your vaccine program in more depth. Just go to: Canid.io/lounge to learn more. 

Transcript

No Show and Vaccines with Chip Hart 

Vaccines are a life saving medical miracle of the last 75 years, but they come at a price that is often significant burden to independent pediatric practices. Luckily, our friends at PracticeWell A not for profit community of and for pediatricians are dedicated to helping pediatricians do the right thing and vaccinate children.

That is why they have provided a generous corporate sponsorship for today's show. Please visit practicewell. org, practicewell. org, p r a c i t c e w e l l. org or click on the link on the show notes. You can join for free and if you mention the Pediatric Lounge, they will set up a free consultation on your vaccine serum acquisition

[00:00:52] Dr. Bravo: Hello George. It's Tuesday morning and we got a great guest today, one of my really dear friends and another data nerd chip Hart. Yeah, we'll be talking about no shows, short-term capital and autonomy. 

[00:01:04] Dr. Rogu: Yeah, today's gonna be a great day. This is a follow up with Chip. And Chip is always a great podcast when we hear his knowledge.

[00:01:13] Dr. Bravo: Welcome Chip. 

[00:01:15] Chip Hart: Yeah, no pressure. I'll do my best. 

[00:01:18] Dr. Bravo: How are you doing? 

[00:01:20] Chip Hart: I'm doing all right. You guys are gonna be really the first people I've spoken to today, except you know my dog and my wife briefly, so We'll, well, you gotta warm up my brain and I see that you've got some pretty expansive topics to talk about, so this is gonna be fun.

Let's see, let's see what we come up with. 

[00:01:38] Dr. Bravo: Well, I was fascinated and we had this conversation. When did you write the blog on NoShow? Think it was maybe 18 months or two years ago. 

[00:01:46] Chip Hart: Well, it was pre Covid, so you gotta add like two or three years to everything. Okay. Yeah. Yeah. But it wasn't long before Covid.

The work that we did on NoShow I ended up presenting at the oh, what's it called? The Predictive Analytics World Conference in Las Vegas. Of all places. They have a healthcare segment most of which is dedicated to how to predict that your senior patients are gonna come back into the hospital.

I mean, seriously, that's like what everyone cares about is Medicare. And so when I gave a pediatric presentation, it was kind of exciting and we'd engaged a company called Rexer Analytics out of Cambridge. They're great, awesome people because we have, at pcc, we have millions and millions of appointments as part of our data set.

And I was really interested in digging into some of the science and some of the behavioral patterns that exist in no-show, because I hear a lot of myths. I hear a lot of storytelling. You know, this, you, you know, you practice. If I say, if I said George Roue, you know, when do your patients no-show?

And you'd be like, oh, Friday afternoons. You know, like, they always bail. And I wondered if that were true, because if it's true, if you know that your patient's no-show on Mondays and Fridays more often, or if they no show more during the summertime or whatever, or the win, I like everyone's pattern's different.

If we knew those patterns existed, we could change. Our practice behavior. And what we found was that, for example, there is no difference between with no show rates Monday through Friday just doesn't, there's no difference. They don't no show more or less on Mondays or Fridays. They don't show more or less with at different times of year what they do.

So I'm gonna interrupt cause 

[00:03:27] Dr. Bravo: he said Yeah, please. You said you've, you've said a couple of things that are very interesting from the data nerd perspective. Mm-hmm. One, what, what is predictive analytics? Is that like forecasting the weather? 

[00:03:38] Chip Hart: Well, yes, but really predictive analytics is, I mean, you've heard these terms.

 It's ai, it's machine learning, and it's it's using data past the data to predict the future. And it's used mostly in my opinion, in the advertising and financial services arena. So when you get a credit score or when you apply for a mortgage or, a car loan if you are walking by, if you get an ad served to you by Google, they're using all of this data to determine what ads to put in front of you because they, they know that this ad is the most likely for you to click on at that moment.

It's, they, they know that you're the least likely to default on this loan. Let's say. . In medicine, as you know, most of the analysis is, is rear view mirror stuff. Like what happened, what happened last week, what happened last month?

How did we perform, what was our E N M curve? And it's very rare that we use medicine in, in pediatrics anyway. Like I, I've talked to you, you guys, plenty about numbers and dashboards and stuff like that. And we don't use, there isn't a lot of analysis in our business where we're, where weak for us to say, you know, we know what your revenue per visit has been the last three months.

Let's predict what it will be. How about, and this is, this was where my dream was headed and I just, and Covid came up and other things happened, but I want to be able to predict because I think we have enough data. I want to be able to look at a pediatric practice like I wanna waltz into R B K Pediatrics and say, George, here's how much cash flow you can expect to get over the next three months because these appointments are booked.

This is what the sick demand looks like right now. This is what your collection rates look like. We should be able to predict that. And the starting point of that is predicting nohow or predicting what your schedule is gonna look like. You have no idea, you can't predict your revenue if you don't know how many patients are gonna come in.

Of course Covid blew that up. We'll see, we'll see where it's going. But that's, that's what predictive analytics means, using the data you have now to predict the future. And most of the time in medicine, we predict the pa, we described the past, you know, chip, 

[00:05:53] Dr. Rogu: I have a question for you mentioned revenue per counter. This is a question that I have with Herb. How do you calculate that? 

[00:05:59] Chip Hart: So there are, there's no right way to do it. There's no, there's no accepted methodology. I can tell you what I do because I work at PCC and PCCs wired a certain way, and it's a way I think. And so all my benchmarks are sort of aligned in my head that way.

It's not necessarily the best way or right way to do it. But there is no, there is no clear right way or that's what we would do. So the easiest thing to do, and I suggest this method because it's generally the easiest thing to do, okay? We add up all the revenue you received, including your value-based care revenue, including your performance revenue.

You throw that all in one place, you throw that in there, okay? You put all that in there because it's part of your, part of what you were paid one way or the other. All right? And then you add up all the visits, you had all of them, and that's your denominator. 

[00:06:52] Dr. Bravo: What, what, what is the definition of visit? So if somebody comes in for a strep test, is a strep test, a visit?

[00:06:58] Chip Hart: We count that. Yes. All right. Now there are pros and cons to that. There are, there are pros and cons to that. Now, the big pro is that, you know, if you leverage the law of averages and you presume that behaviors somewhat, you know, regresses to the mean over time, it's a consistent, as long as you're using the number for yourself consistently, it shouldn't matter, however, okay.

One of the reasons why lumping all of that together is important. If you take a look at what happened during Covid, there was a massive increase in covid test only, and Covid shot only visits in practices, massive. And if you in order to calculate that number for your practice, if you're only adding up e and m visits, like six and wells and consults, the things that, that you label a visit suddenly about 20% of your revenue and your, and your schedule was being eaten up by this other thing, this little non visits tumor, let's call it.

And your revenue per visit could have looked good, but you weren't, your revenue wasn't as high because you had to make room for all these, all these extra visits. So I like, broadly speaking, to count every visit, including her, those, those strep tests and everything like that. And, This is the kicker, the vaccines for the cool kids.

For the cool kids, you actually break out your revenue per visit by visit type. So you really want to know how much am I getting for well visits? How much am I getting for sick visits? How much am I getting for what we'll call them? S like other types of visits. Those are telemedicine, e and m's.

Those are consults. Those are in-hospital visits. Those are, they're much smaller. It's a very small segment of your you know, it's less than 10% of your, so 

[00:08:45] Dr. Bravo: before we go down deep into the weeds yeah, because George and I, this constant argument, you know, he thinks that revenue per visit means I take all the revenue you get into a practice, and then I divide it by all the CP T codes that I have for the year.

Oh, not all 

[00:09:03] Chip Hart: the codes, all the office visits or, or physical 

[00:09:06] Dr. Bravo: visits. No, no, no, no. You say everything. Everything. So 

[00:09:09] Chip Hart: you put everything into it. So the strap test, the covid test's, 

[00:09:13] Dr. Bravo: vaccines, the admins, that's all in your revenue. I'm just saying, what are you divided by? If you divided by everything that you did, every CP T kilo you did, you're going to get a number probably in the thirties or forties 

[00:09:26] Chip Hart: per, per, per 

[00:09:29] Dr. Bravo: ct.

You know, actually 

[00:09:31] Chip Hart: it'll be. It's funny because it includes immunization. Yeah. It'll be in the thirties, but the, you're right. So what I would tell you is, no, I wouldn't divide it by all your C P T codes. Obviously. I think George is shooting for all your e and m's, either, whether you're count up, what you would call a full visit, e and m, sick and well those others, or you count all the appearances of a kid in your office that day, which is what we count at P C C.

The most important thing is what either method misses something. So if you use what I'll call the P C C method, which is to count every appearance of the kids' in your office, a as you're benchmarking yourself, remain consistent and use that benchmark, but then go the second step, which is to actually break it down by, by visit type.

If you're only doing it for the chunk of e and m counters that you do, you might want to pull out all the revenue you get from those covid only tests and covid shots and strep tests, because then that revenue, if you don't, you're counting revenue for a visit where you're not, the visit also isn't in the denominator, and so you gotta, and you're 

[00:10:42] Dr. Bravo: pulling out this data, then you're pulling it out from the schedule, not, not from.

You're counting, you're, you're counting how many people were scheduled, or, I mean, how, how do you pull up? Oh, 

[00:10:52] Chip Hart: so that's, oh, that's a, that's a really, that's a good nerdy question. And what I'll tell you is P c C doesn't pull it out of the schedule because we have, we're able to actually look at the charges and say, all right, we can, we can calculate visits from the charges, because there is, in fact, at every single practice I've ever worked with a difference between what's in the schedule and what gets billed.

For good reason. It's not like mistakes are made, but even though that does happen, it's more like some, sometimes you charge things, they weren't in the schedule. Sometimes the doctor does something and they didn't put it in the schedule. That happens for the people who still go to the hospital, for example, or a lot of telemed stuff, especially at night.

That stuff doesn't show up. And also, there are plenty of visits, too many visits that gets scheduled, and the patient doesn't show, but they're not marked as canceled, as missed, or if there's a zero minute appointment made for some purpose as a mark, or it's been crazy what people do. And so , what we do is we back out and say, all right, we're gonna look at everyone who got billed out today.

And every, on any single day, any single appearance of a patient will be, we will consider to be a visit. Okay. It's not perfect, but. It's consistent. And then if we go the second step of breaking it down by visit type where we, where we actually say, all right, look for a 99, 3 91, everything that happened that day, we're gonna count as a 3 91.

And what does that 9 93 91 visit look like? I think that's the only way you can do it. What about the vaccine serums? Where does that get put? So what personally, I count all the products. All right. And, and I realize that that's also imperfect. All right. That's why, I mean, George, you may remember this from your dashboard date of pcc.

That's why we have a revenue previs with and without vaccines. Yes. Because as, as a business owner, you have to include the vaccines. It's, for most of you, it's 25% of your revenue. All right? You have to include it. That's, it would be weird not to make that part of your analysis. And you should be understanding whether or not you are profitable or losing money on the product.

However, if you want to benchmark your performance against the rest of the country, where you have people in 90% Medicaid, you have people who live in universal states, you have to exclude the vaccine for all the other performance. Cuz the vaccines absolutely sort of overwhelm or push out the ability for you to do the analysis.

The, the other thing I'd add is that issue is only getting. Bigger, not smaller. 20 years ago, I never even thought about whether or not to include vaccines in the revenue because it, it was 10% and 10 percent's a lot. But it's not like, you know, it's not like it was a huge distinction among the practices.

It's just 10%, maybe even less sometimes. But now it's like 28 to 32%, 25 to 32% and that's, that, that wrecks all the numbers. 

[00:13:44] Dr. Bravo: I I gotta keep interrupting you cuz I'm a date please. But when you say 28 to 30%, you are talking about a practice that's mostly commercial. Cuz if you start talking about a practice that's 85% Medicaid, they're not, you know, they're, they're 

[00:13:59] Chip Hart: correct.

You, you, you're totally correct. However, well, lemme 

[00:14:02] Dr. Bravo: say this and then you get, you get, you know, remember 50% of the kids in any given state in America are now on Medicaid. So a large practice that takes, everybody's gonna have 50, 60% Medicaid, they're not gonna have 30% of vaccines. So 

[00:14:17] Chip Hart: the diff no, but let, I will give you number, so, okay.

All right. So here's the thing. About 30% of PCC clients' volume is Medicaid. Okay. All right. And now when, just as an aside, you know, when someone says I'm 30% Medicaid, you always have to say, is that dollars, is that visits or is that patients? Right. Okay. And for us it's 30% of their. Patients. All right.

Okay. I'm off the top of my head. I can't tell you if that's 38% volume or 25% volume, but it's about 30% of volume by patient, active patient count. Okay? We obviously have clients who are at 95 and a hundred percent. We have 12% of our clients are at 0%. Yes. 55% of the children in the United States right now are on Medicaid.

However, a huge chunk of those kids do not have pediatricians, do not see pediatricians or do not go to an independent practice. Huge chunk. They go to RHCs and FQHCs, and they see indep, or they see, you know, FPSs and internists. And I mean, like all that stuff is true. So our clients see 30% Medicaid, even with across all of our clients.

Okay? Even with that 30% Medicaid volume and practices in, we have plenty of practices in universal states. All right? Which is the same thing, right? I believe vaccine product is in 2022 was about 23%. I am saying this off the top of my head, but it was about 23% of all the revenue our clients received.

[00:15:51] Dr. Bravo: I'm gonna circle back to this. Yep. This, this is another, you know, so We have somebody who listens to us in California, and she's phenomenal, Sabrina. And she says, you, you and George, look that the car talk of pediatrics. Do you remember that show on npr? And it's, 

[00:16:06] Chip Hart: I, I remember 

[00:16:07] Dr. Bravo: it very well. I love that car show.

This was my Saturday go show. And George and I argue a lot about the numbers cuz I don't think he understands math, but nice 

[00:16:16] Chip Hart: guy. But he's willing to argue with 

[00:16:18] Dr. Bravo: you about it, but he's willing to argue with me. Okay? Yep. But what is the important parsing all this out. Why, why don't we collect datas?

Why don't we build dashboards? I mean, why? Because it entertains me. Cuz I like math better than dealing with people. Yeah. 

[00:16:34] Chip Hart: Well there could be an element of that. All right. I give a big dashboard talk. I tell people the same thing every time, and it usually clues them in.

Would you, would you treat a sick kid without taking a temp and a pulse and a blood pressure and some labs? No, of course not. I mean, you can, and there are times when, you know, most of the time you'd be right-ish. Think of all the data you collect as a, as a doctor, which is a form of a scientist.

All right? The scientific method is, Arguably the single most important thing human beings have developed in my opinion. And when you have a hypothesis, you can't prove it with your feelings. All right? And I am gainfully employed and you guys are like, you know, now in the business you will be gainfully employed because too many doctors use their feelings about how their practice works instead of the facts.

 The numbers are the fact, and I, you know, you can tell me all day long that you have a hundred percent vaccination rate in your practice and you never miss a kid. But until you show me the receipts, doesn't mean anything. Well saying, let's look at the numbers. You are correct on that.

[00:17:55] Dr. Rogu: 95% of the time Herb was correct also with the dashboards. But in my experience with both of you guys, my feelings were pretty darn close to your numbers. But the numbers more important. I agree with you. So you're supposed to use the numbers, not as absolute as a warning. Warning. There's a problem.

[00:18:13] Chip Hart: Warning and proof. See 

[00:18:14] Dr. Bravo: if your feelings are, so there's a point. So, okay. I have even an even si explanation back to the car talk show. There's a reason why my cars, which are all Mercedes and they're all gasoline driven have a gas tank gauge. It's because I don't wanna run out of gas on the highway, cuz there's no way of knowing how much gasoline is in my tank.

So when that little yellow light turns on, it means I gotta stop now and put gasoline in my car. If you don't ha, if you're not gonna use the data that Chip provides, or that we provide, or that whomever provides for you to make decisions and change your behavior, let's not waste time. You are correct. So that's what the next, you know what you're doing and let's not waste time.

David, data discussion 

[00:19:05] Dr. Rogu: we had with that student Yes. Says the, A dashboard is there for you to analyze, to figure out stuff, and then you have to act on it. 

[00:19:15] Dr. Bravo: If you're not a action, when your, when your gas gate says it's in yellow. Yeah, well then just yank that thing out and drive until you get run outta gas.

And 

[00:19:26] Chip Hart: then I'm gonna, I'll say two things. I'll say two things about this. Number one, George, you're right. I mean, the overwhelming majority of independent practices survive. Yeah. Because they gen, you know, I'm making payroll, I feel like I'm making okay money. I know I can make a little bit more, but so it, it, it's not like most of the time the pediatricians are really far off, but I guarantee every practice I've ever worked with, including yours.

Yeah, you have your finger on a couple things, but there's always something you're not feeling and you're not seeing. And that's why like sort of, it's, it's like a, it's like a getting a panel. Okay. You like ding, ding, ding, ding, ding. Oh, the PSA is too high. I had no idea. Like you wouldn't know unless you did it.

But here's the other thing. So, but speaking the PSA to psa, being high doesn't mean you have cancer. It means Correct. Take a look, analyze, figure out what the problem is. You want Totally resolve it. Totally true. Right. All right. Number two though, even lowly pediatrics, and I'm like lowly pediatrics, that the, that we all work in the specialty that gets the least amount of money.

I think it was Bloomberg just released their latest numbers or whomever it was just release their, release, their latest numbers. Even pediatrics has so much cash flow. That your margin of error as a business owner is so big that you can make mistakes the whole way through the number of, I mean, literally million dollar mistakes that I have unearthed at pediatric practices.

Individual pediatric practices mm-hmm. And they just cruise along. It just means they didn't, you know, over a course of 10 years, this poor doctor made, you know, 1.5 million instead of two or 3 million, like they deserved. Well over 10 years back in the two thousands, 1.5 million, you're still in the 1%, you're still sending your kids to college.

You still have a mortgage. Most, there's so much cash that flows through that the, even the people whose feelings aren't good or aren't accurate still survive. I think if you lived in a more if you had a lower cash flow business, you would be more attuned to your, to your numbers. That's my 

[00:21:34] Dr. Bravo: I agree.

Experience. And, and to me it just, you know, and I think you, you have a lot more experience than I do. I've seen ophthalmologists, orthopedic surgeons, radiologists, pediatricians, and you walk in and they all have the same common problem. Revenue cycle manager, it's a big one. They don't know how to do that.

And it's exactly what you said. You look in there, depending on the size of the practice, there's millions of dollars lost. They're just sitting there. Nobody ever worked collections. Nobody ever appealed it. Nobody, nobody had a flag to raise so that the managing partner could know there's a problem. And it's, but they're making plenty of money, so they're like, okay, well my life is good.

Why should I have another headache? Yeah. And the insurance comes and you love it. It's like, 

[00:22:22] Chip Hart: yeah, it, they make my money, money every day. Keep that, 

[00:22:27] Dr. Bravo: keep leaving that money in my pocket. I don't care. 

[00:22:31] Chip Hart: Yeah. It's organized crime or it's like organized crime. Like organized crime. Yes. Like organized crime. It's the only business where you make more money if you're bad at your job.

Oh, we forgot to pay you. Oh, last time I said that you yelled at me. Yeah, yeah. Or no, it's like the insurance companies, oh, we made a mistake and we shouldn't have denied those claims, or we should have paid you. Oh, our bad. There's no, there's no actual repercussion for them doing their, their job poorly, except for they make more money on the float.

[00:23:04] Dr. Bravo: Okay. So here's another click and click argument. We ran some numbers with our coaching group, right. And the difference right now there's a lot of confounding factors but they're, they're super performers. So they're getting on the average about $150 per revenue by encounter. Per visit. Per visit, yeah.

And if you add the vaccines, they're getting 153. That's a little bit more than what you say, your your 

[00:23:32] Chip Hart: best, you're saying, you're saying it, it's a four and a half percent difference. So you must have practices with a lot of Medicaid and or are in in universal? No, they, they 

[00:23:40] Dr. Bravo: have, they have anywhere between 40 to 60% Medicaid.

So their, their re you know, their vaccine revenue is only 10% of what they collect. Okay. So it's a, you know, they're different practices, but the, the, the differential there is not a lot. But they're doing great. I mean, your K ps of 140 for the average practice per visit. So it's they're above the national average.

Now that's all funny business too, right? Because we've been testing for a lot of covid. That gets reimbursed very well. And that's gonna go away. So that, well, are you, 

[00:24:16] Chip Hart: are you counting every visit to the practice or are you counting just the e nms? 

[00:24:21] Dr. Bravo: I, you know, they're not on p CCC chip, so I have to do what I can do.

So I, I count all the ENMs as a, which is fine. No, 

[00:24:29] Chip Hart: that's a perfectly reasonable way to do it. I said then I'm an, I would not, I would not then compare them to us, because right now the non E N M visits are in some cases 25% of the volume of a practice. So comparing, so are there still people that go just for COVID test?

Oh yeah. 

[00:24:49] Dr. Bravo: We don't do that. Oh yeah. Yeah, we don't have many people doing that. We 

[00:24:52] Chip Hart: don't have that anymore. We, everybody actually in for a visit. And in that visit, you do a test the way it's opposed medically, you remember the way your reports used to work in P C C, so we would group them by default.

All right? It was like, well visits, sick visits, consults, hospitals. We actually had to break out during Covid because it, because this tidal wave of visits came in that needed re categorization. We had to break out telemedicine visits because before covid they were 0.3% and they got as high as, you know, 20%.

And then we had to break out covid v what we call covid visits. And yeah, we still get a fair amount of those. And it, of course, we have some, we have clients who never did anything. We have clients, we have a ton of clients who never gave Covid vaccine. And then we have clients who gave out six figures worth of covid vaccine units, not, not dollars.

And so, yeah. The, the variance is significant, but yeah, the most important thing, I mean, you know, this when you're doing benchmarks, is to continue to measure against yourself and, and people who are measured the same way. That's, that's the important thing. Okay. 

[00:25:54] Dr. Bravo: And now I bring this up because I'm gonna get back on topic.

We, we figured that a well run practice is about 5% no shows in any given day. Mm-hmm. And that has a, an impact on your revenue. If you can make sure that 5% showed up, you'd be better off. 

[00:26:15] Chip Hart: Well I think it's generally true that if you actually know who's gonna come in, your life is a little bit easier.

5%, one kid a day, you know, some practices, believe it or not, I've, I've even been told to straight up some practices actually like having a certain no-show volume because it gives them flexibility within their schedule. I think that's a little crazy, but I have heard that, but 5%, 5% or less to me isn't a problem.

When the problem becomes, when you approach, you know, 10% or higher and when even when you correct for the primary variables that affect your no-show rate. If your no-show rate approaches a certain percentage, I don't know what that magic number is you, your practice becomes too chaotic and it leads to actually you most people think right away, oh, if my no-show rate's 20%, that means I have a lot of empty, I have a lot of gaps in my schedule.

And in fact, the opposite is often true. If someone has a no-show rate of 20%, what they often have is too many people crammed into it. As a result, they know the no-show rates 20%. So they overbook by 30% and when it just so happens that eight people actually show up at 11 o'clock, you're working through lunch.

And it's bad for them and it's bad for you. That's the, the real problem with no-shows is not that you are seeing fewer patients, it's that you can't predict your schedule and you sometimes have too many and you sometimes have too few. The patient volume in our clients with high no-show rates is higher than it is with the ones with low no-show rates.

[00:27:57] Dr. Rogu: But I think that it's not a bad , that, I hope that makes sense. I think that model, I think that model where everybody's booked at one o'clock and everybody shows up and then they'll see 'em for the rest of their day. That's a model of like, back in the day, herb, remember the clinics? Yes. Yeah. Hospital clinics, everybody gets booked at one o'clock. Everybody shows up around the same time. Half of 'em don't show, and then you have a full day. I don't think private practices actually do that model. I don't think so. 

[00:28:23] Chip Hart: Oh, there's absolutely someone do that. Yeah. I don't encourage it. No, I don't encourage it at all. But obviously some practices that may not be well run some practices that are super high Medicaid, so they're acting like a clinic. Anyway, I am a very. Big believer that pediatric practices need to focus on preventive care. Preventive care is the heartbeat of your practice, and you can't focus on preventive care if you can't schedule it in advance.

All right. That's like the whole purpose is that you have a schedule, you have a calendar, and we need to do these things on a schedule. It's not on demand. It's projected. And so those practices who have there's one big exception, I want to talk about an exception a second, but those practices who have a lot of scheduling, chaos, don't have generally have great well visit coverage rates.

They don't. One big exception is this, there's one big exception, and I've seen this work incredibly well, are those practices who do an early morning walk-in clinic? Mm-hmm. So I know some practices who are like very, very successful in accomplished pediatric practices with a high focus on preventive care.

What they say is from seven to 8:00 AM we, you just walk in, don't call, show up, and we, they'll crank through, you know, a pile of kids in an hour because those seven or 8:00 AM things are, you know, and they tell people this is for a fast acute visit. All right? This isn't for your three months of headaches.

This isn't for your eating disorder. This isn't for a well visit, but if you are sick, Show up if it's an ear thing, a throat thing, a rash, whatever, show up and they bang, bang, bang. And you get, you pull all of those five, 10 minute visits out of the schedule early in the morning, keeping people happy. That gives you time to spread out a little bit in the, in the later day.

I have seen that done very successfully.

[00:30:14] Dr. Bravo: We hope you're enjoying this episode. As you know, George and I are passionate about independent community pediatrics. We honestly believe this is the best care for children across the U. S. George and I say this time and time again, the chances are high your vaccine program is not as effective as you think.

After factoring in time, waste, fees, and the many other costs, many practices barely break even. That's where Canid comes in. They do everything from buying the vaccines to managing all the paperwork to making sure you get paid fairly for both private and VFC vaccines. You simply scan the vaccine and you're done.

We partner with them to offer you a free lunch where they help you understand the financials of your vaccine program in more depth. Just go to canid. io backslash lounge to learn more. That's C A N I D. io backslash lounge, or look for the link on the show notes. 

[00:31:22] Dr. Rogu: Do you ever, of any practice that did same day well visits, what do you think?

[00:31:27] Chip Hart: Well, , y'all do to some extent, right? Yeah. Like there, there's that mom who calls and says oh, oh my God. I am sure that we have practices who have, who have experimented with all on demand scheduling and obviously practices who are in growth mode do that.

You know, the phone rings, you say, come in and you're not actually filtering any visits. They'll do more of those. But an established practice as a rule has usually a couple week wait. You can't just waltz in today and get a well visit unless there's some, you know, extraneous circumstance that's, that's direct.

[00:32:04] Dr. Bravo: So from a, from just from a money perspective, if you lose 10% of your visits, you know, in say, I know it's a little less than that, but an average pediatrician makes 5,000 visits a year, right? That's what they see. 4,000. Oh, fewer 

[00:32:18] Chip Hart: than that. It's actually fewer than that. But what do you think use 5,000?

It's easy to multiply. And these dates, 3,500, just so you know, 3,500 is the cutoff. Alright? 

[00:32:27] Dr. Bravo: But if, if you do that 5,000 times, 10%, that's times $155. That's $77,000 per doctor that you have that went out. Yeah. So, you know, and, and you know, it's gonna vary on your, you know, your payer mix and how, how many patients this doc sees versus that other doctor.

But it, it's not, it's not 50 bucks. You know, 77,000 is half of, almost half of what the average pediatrician makes in America, 180,000. So, you know, it's a significant amount of revenue lost. So what did you find out when you dug deep into this? All right, who's, who is likely not to show 

[00:33:07] Chip Hart: up? So, a couple things.

First of all, there are a bunch of vendors out in the market who sell no-show solutions. All right? I've tried working with a couple, with a couple, I've yet to find anyone who really certainly can manage it in peds. And one of the first, the first premise you have to address is that a 10% no-show rate means in fact, you can increase your patient volume by 10%, that you've actually lost 10% of your visits.

Because in reality, you haven't, you've overbooked your practice in order to have the volume that makes you. Get to where you want to be. I mean, that's, that's just how it works. It, it's, it's, you're reducing chaos and you're creating predictability. When you fix your no-show problem, you're not, it's, it's in pediatrics at least, you're not staring at empty slots as a rule.

What we discovered though we discovered a couple things. We did discover in fact that obviously this was no surprise. People without insurance and people with Medicaid have a much higher no-show rate. That's a fact. And we can attribute that to all kinds of things, not the least of which is challenges that that population has with have with work and transportation.

But if we isolate for Medicaid and lack of insurance, and, and by the way, we did all of this before covid, and as a result of the Covid emergency measures and so forth the Medicaid population has changed quite a bit. It'd be really interesting to review that data post Covid to see what the implication is.

But what we then looked at was alright. If we, if we isolate lack of insurance, if we isolate for Medicaid, what other markers are there? And the single biggest marker, this is going to sound really stupid or like obvious, but to me it was a revelation because this changes, this should change the way that everyone's schedules, the single biggest predictor of somebody no-showing is whether they no-showed last time.

And so it's like massively. I mean this was years ago, but I actually, George, I think you even responded to my blog post at the time. It was like, this is, it's like the 80 20 rule, but it's really like 90 10. It's about 10% of your patients make up like 60 or 70% of your no-show. It's a very small part of your population.

It's a very small part of your Medicaid population who does this. And so the over under was that as soon as a family is no shows more than 10% of the time, which you're like, what? What does that even mean? It means if you have a family who is not no showed with three kids, and by the way, it's based on the family, not just the one kid.

You have to look at all the kids on that family. But if you have a family with three kids and they have shown up for all their visits for years and they had a no show, That's not a good predictor of the next no-show. But if you have a family who no-showed at their second visit or at their fourth visit, you need to put them on the high flyer or the low flyer list as soon as a family no-show.

Usually it's like more than once, but it's like nohow is for 10% or more, 9% technically, but 10% or more of their visits. Then you should mark them and you should check with them leading up to the appointment in person. And what I mean by that is everyone here has reminder tools, okay? Everyone here like has automated tools that text your patients and give you text reminders.

And that works for helps a little bit. But every day you should look at your, your schedule and if, if you have, all right, let's say you're a five doctor practice. So you have you have 200 kids coming in today, just making that, oh no, 200 kids. That'd be way too many. Let's say you have a hundred kids coming in today, 110 kids coming in today.

If you have 10% of those families are the no-shows. Your staff makes 10 phone calls in the morning. It's as simple as that. That will do more for your no show rate than anything else. You, you know, the 10 families, the odds of those other families not showing have everything to do with things. Those families don't know yet.

Something happened at work. Their car got a flat, they're, you know, I mean like they overslept. They overslept. Yeah. But you, you two guys right now, you guys don't know show for doctor's appointments. But if you had a doctor appointment at four o'clock today, there are many things that could happen to each one of us before four o'clock that would cause us to nohow.

It is, there's nothing anyone can do about it. And these people don't want a nohow. But if George Roue is someone who knowshow half the time, or let's just say he's no-showed twice already, you should call him this morning and get him on the phone and you can make rules for those people. You can say you have now no-show twice, three times you do not get to make appointments.

You are same day only. Oh, 

[00:38:01] Dr. Bravo: I love that. So, so if you know this is a high-risk basin, they call and say, I wanna see you. Cause that's the other thing you found out, you're more likely to not show if the appointment is scheduled three days in advance 

[00:38:12] Chip Hart: or more. Correct. So nohow almost never occur for same day appointments.

So if this is a 

[00:38:18] Dr. Bravo: patient, that family that chronically nohow. And they want an appointment for three days. You go, we'll call you, you know, whatever. Today's Tuesday, we'll call you on Friday morning, tell you what appointment's available, see 

[00:38:30] Chip Hart: if it works. Yep. And if your, and if your kid is sick, if your kid is sick, you call us that day.

We'll figure out how to get you in because for one kid, if you can make that, you do that for one kid. All right. Take the tricky part. And it's a Medicaid kit. Yeah. 

[00:38:43] Dr. Bravo: The tricky part there is and we had this conversation before, what do you do with these families to get their well child exam done? 

[00:38:52] Chip Hart: That is, you're absolutely right.

That's super tricky. And that's where I have a couple suggestions. One of them is, all right, if you have a 10% no-show rate, which is where you start, you're really starting to struggle with managing your no-shows, all right? Rather than book, rather than overbook all of your families indiscriminately. So like, all right, so if you have 10% no-show and you wanna see 20 kids in a day, what a lot of people do is they book 25 kids knowing they will overbook five of those slots, knowing that somewhere between zero and five people will no show today.

All right? On average. And so what that means, every now and then they see 20 every now and then they see 25, but most of the time they see 22 and a half. And it kind of works out. However, when you overbook those five slots, you're doing it like at nine and 10 30 and 12 or whatever. Well, what happens if the overbooked slot you get.

Everyone shows up. Why not overbook only with the people who no-show the most. Why not put all of your no-show high, no-show people at the time, at the least desirable time of day, give your people who, who want that early appointment or whatever the case may be. You know, I don't know what the demand is in your office.

Why not give the, the, the people who show up you give them the best times and then you overbook your no-shows for the same slot, because then it's most likely not to be, to crash your system. 

[00:40:25] Dr. Bravo: Great. How about putting 'em on a wait list and you know, for the well child, like I know absolutely. That that is absolutely.

I know when your birthday is technically May, I'll put you on a wait list for May for your you know, for your physical, and then I'll call you every weekend, say, Hey Chip, we got physicals tomorrow. We wanna come in. Or how about you come in on Thursday and I keep coming all 

[00:40:48] Chip Hart: month long. Yep. That is, that is the kind of planning that a pediatric practice has to do in order to generate revenue while making their community healthier.

That is, that is the hustle. That that's your hustle. You just described it. What you just described is what every practice should be doing, in my opinion. Okay. 

[00:41:07] Dr. Bravo: All right. Cuz I, I like. I've seen it both ways. I, I've seen, I help a clinic out that is 85% Medicaid, near Quantic and Marine Base. Right. And Yep.

They overbook, they don't, they don't count for Nohow, they just delete 'em from the schedule. But everybody that you see, I wouldn't do that, but I under, I understand, but not everybody that you see when you look in ec, worthless, I can say that cause I'm a pediatrician. Yep. They have their next well child appointment already scheduled.

It gets done. They come in with sore throat, gets done in the front desk. They come in for a sprained ankle, it gets done in the front desk. They come in for their two year well child exam. They've already scheduled them for 365 days from today. You know, and they have all the reminders and they have no shows, but she's tremendously busy.

You know, and I I, I, 

[00:42:04] Chip Hart: I know I advocate 

[00:42:06] Dr. Bravo: count 'em, count 'em, I count him. Yep. See how you can do that? Maybe you could get another doctor, you could get two days off, you know, instead of having to work five days a week, whatever. Yep. But, but that system does work even in a high Medicaid population. Yep.

So, you know, and that's what you, I 

[00:42:23] Chip Hart: I will tell you, we have. We have practices, we've had many practices over the years with very high 60, 70, 80% Medicaid populations. Mm-hmm. Who do extremely well with, well visit coverage, H P V vaccination, all the markers, all the things that, that some doctors tell me, well, you know, you can't get the Medicaid kids in.

You can, you can, if you build your practice around it, you can. If you build expectations, it it, are you gonna bat a thousand? Of course you won't, won't. But just like we know that the level of H P V vaccination in a practice is wholly dependent on the physician attitude, not the population. I mean, like, I've had too many people tell me, oh, you don't understand my patients.

And I'm like, I got someone on the other side of town who has the same patient base as you do, who does twice as many H P V shots. And that's because they care about it. Because they believe in it and because they actually promote it. You just haven't, you just haven't fought about it. You, and the same thing is true of getting your Medicaid kids in.

So, Herb, I agree wholly you should treat your Medicaid families like the adults they are and get their well visits booked and you do your hustle to get them in. Everyone's a little bit different. There's a balance. But I am also a fan of what you described. 

[00:43:39] Dr. Bravo: So, you know, to succeed you need to have good tech cuz you know, you need to be able to figure out what you're scheduling.

You need to have good people and you need to have a process in place. That process may vary depending on, you know, how you want to skin the cat. Yep. You know, 

[00:43:58] Chip Hart: and Yeah. But just skin the cat don't give up. Right. Don't, don't, don't tell me you can't do anything about it. Have you? Can't the process 

[00:44:05] Dr. Bravo: and check on the process, because if you don't check on the Absolutely.

Then, you know. Yeah. I mean, if you just tell the staff, schedule everybody for their wealth and you never look, if they're doing it, they'll forget. 

[00:44:17] Chip Hart: Right. And or, and you never look at what your coverage rates are. You never look at what your no-show rates are for those visits. You never look at whether how many times you've called them and whether you made contact.

, the big lesson is, no matter what I say right now or whatever you two guys say doesn't matter as much as the fact that you're actually working on doing something to improve your no-show rates in your practice. Everyone's different. You might, and someone listening might have a cool idea that we haven't tried or we haven't mentioned.

Nothing wrong with that. Awesome. Just do something. Don't tell me it can't be done because it's done all the time. 

[00:44:50] Dr. Bravo: All right. And then I'm gonna, I'm gonna, this wasn't on the to topic, but vaccines are important to some practices, greater to some practices than other practices depending on the state you are.

So when we're just talking about vaccine serum overall, what is it? What is a good margin? 

[00:45:05] Chip Hart: So, that's a good question. I mean, the aaps white paper and research on this is good. I have no reason to disagree with it at all. I think you really want to shoot for 17 to 25% or 28% so, you know of yeah, of margin over your o over what you paid.

 As a rule of thumb, I use 25%. Now, I know a lot of people who don't get anywhere close to 25%. And one element of the discussion I don't think is, well, I don't wanna say well understood, but it's weird to me how people don't think about it this way. I feel like I'm bucking the trend a little bit, or I'm sailing into the window a little bit on this and I don't get it, and I'm waiting for someone to educate me.

But the bottom line is you can't give the vaccine without the admin. So you can't do an analysis of your, a true full analysis of your vaccine profitability without including the admins. Okay? And the fact is, all right, this is not universally true. This is just generally true. The fact is, for whatever reason, the payers pay a decent profit on the administration, most of the time, not all the time, plenty of, plenty of greedy, evil examples, but on average, Right.

With payers paying, I can look up what our numbers are right now, but payers pay about 20, 25 bucks on average for a 9 0 4 60, and they pay 10 to 15 bucks for a 9 0 4 61. Mm-hmm. You give that MMR and if you're breaking even on the mm r product, but you get 20 bucks plus 12. Plus 12, okay. It didn't cost you 35 bucks to administer that vaccine from beginning to end.

It didn't. All right. If you combine the profit of the admin with the profit or not of the of the product, the you will, generally speaking, I think pediatricians farewell, of course your mileage may vary. Like I know practices who get screwed by this stuff, but I know practices who, for whom vaccine business is without it, they would be in big trouble.

I don't like to really dwell on, frankly, I don't like to dwell on vaccine profitability too much because I think it plays into the hands of the people who our anti-vaccine You know, they believe that pediatricians give the vaccines because they make money on them. We know that they give vaccines regardless of what they're being paid.

 No. Pediatrician I know looks has a kid in front of them and says, no, I I'm not vaccinating you. Like I've never seen that once in my whole career. They vaccinate like they breathe because you all believe in it. And that's the way it should be. However, yes, for us as a society to depend on you to eat the costs of vaccination.

Yeah. That can't be done. I'm not having that. I'm not having that. So No 

[00:48:08] Dr. Bravo: should be, but to your point, so I break it down by different I call 'em revenue centers. So there's a revenue center, that's your lab. There's a revenue center that's your vaccine serum. There's a revenue center that is your vaccine administration.

There's a revenue center that's your sick visits and there's a revenue center until your well visits. And then there's a no revenue center, which is all the screening that we do that barely gets paid for. And if you're just looking at the vaccine serum, The true number on margins is somewhere between six to 12%.

And I don't care who you tell me you're buying the vaccine product form. 

[00:48:45] Chip Hart: . All the GPOs are within, are very close to each other. And, and when I 

[00:48:48] Dr. Bravo: look at the data and I look for one practice, practice, I can't do this on screen, but you know what I want to do with my middle finger.

Yep. Okay. Yes. The problem here, which is a tricky part when we're working one of, with one of Georgia's medical students doing data analytics, is that people think that if they just take you know, we all know what you have to pay for for a varice vaccine, 250 bucks, that's the CD says that's what the commercial valley of it is.

And you say, well, I, you know, it's costing me two 50 and I'm getting paid 2, 2 75. So the margin's $25. Wait. Let me tell you something. On a $250 or 300 vaccine, if you missed 10 that weren't reimbursed, you're un you're losing money. You cannot just say, oh, , this cost me this and this insurance pay me that.

My margin's 25 bucks. You don't know that's your margin until you got that money back into your pocket. So you really have to dig deep to get into whether you're losing money. And a lot of times you're lose losing money simply because their revenue cycle manager sucks. And they didn't get picked, things they 

[00:49:58] Chip Hart: gave.

I wholly agree. I actually, I don't know if you've seen it on my blog, but I, I built a little IMS analysis tool specifically to do this work. And one of the things I learned, all right, I used to really be into going through the costs of the different elements cuz the part that people don't understand that when you, when the, when you're talking about vaccine product profitability, okay, you have the expense of getting the vaccine into the fridge, and then you have the expense of getting the, from the fridge into the kid, the fridge into the kid is the admin part.

But all the work that you have to do to get that vaccine into the fridge, the time spent talking to the GPOs and figuring out which one you want, the time spent ordering inventory management you know, the losses from dropped or broken vaccines or ordered vaccines that can't be given or unpaid vaccines or you know I actually have compiled a long list.

That expense is often overlooked. I'm surprised actually that you're seeing numbers between six and 12% because I have plenty of clients for whom that number is, is closer to, to zero or even negative because of the expenses that are related. And I think it I think it's made worse.

I don't think it, it's made worse. I know it's made worse when you combine, when you have a practice that does V F C and private stock because you have additional overhead with, you have an additional refrigerator often. All right. Or, you know, you certainly are managing stuff differently. You of two sets of inventories, you are getting audited.

You ha I mean, cuz the V F C program is punitive more than supportive as a rule. I think there are two or three. I, agree with you that looking at that at, at these different cost centers is a really important way to look at it. Personally, I combine the admin in the product because you can't do one without the other.

It's not, it's not possible. So I combine them. However the broad cost center of vaccines in pediatrics is still not really fundamentally understood in our business. Independent practices deliver the overwhelming majority of vaccines in this country. Yet no one really quite understands what the chain is.

The, the pardon me, the financial chain of that's not, 

[00:52:17] Dr. Rogu: you would think after the covid thing. We should know how the financial chain goes when it comes to like negotiating a contract. Every company uses a different formula to determine the value of the vaccine. Zero. What do you think is the best one?

[00:52:32] Chip Hart: Yeah, I think the only one that matters is , the c d c public sector price. Cuz it's the closest to what you pay all this other, that's the one that they don't use. Yeah. And I Do you think that's coincidence? Of course you don't. I mean, you know, it's bs All right. Like, that's, that's exactly what's going.

These, they use the a W P and the Red book and all this stuff that's hard to find. That is just conscious obfuscation. , the people over on the insurance side are not idiots and they just, it's all a slow down and let's make this a little bit hard. It doesn't, you know, and that's where, I mean, you know, this, you look at what they are offering for payments on the, on the vaccine.

Even if they're using some weird a w p thing, you say, but still gimme your number. You look at their present numbers, you look at what you get paid for the admins, and you calculate it that way. And more broadly, you back up and say, what is my average revenue going to be for this, for this payer? Because, you know, they play a shell game.

They move some money from here to here. Okay. In a way, I don't care if they don't wanna pay me for an mm m r at all. If they wanna pay me zero bucks for an mm m r. I'll accept that if they're paying me 210 bucks for that, well-visit code, right? Like it all, you just, you really have to look at the big payment picture.

As, you know, people wanna zoom in. I'm getting, you know, I'm getting screwed by Blue Cross because they don't pay me for X. You probably are, but maybe they're doing well on the other side and it's really another payer who's just generally lower on everything. Oh yeah. I mean, cuz I, I remember this George, you and I have actually had this talk way in the good old days.

Well, when the payers would come along and say, I'll pay you for that 9, 9 0 5 1, I'll pay you 10 bucks for that after hours code. And people get excited and they chase it and sign that contract and I'd be like, you know, all they had to do is take a buck off of every one of those e and m's and you just lost money and Great.

So you really gotta look at, you really have to do all the math all the time and you gotta come 

[00:54:34] Dr. Bravo: concentrate on your bigger revenue centers. Yes. And that's where you're gonna create your negotiation. The other one really, you know, the other stuff becomes, yeah, okay. It's icing the cake, but you know, I've already had the cake and Yeah.

So just to recap here, it doesn't matter what G P O you're using, you're probably not gonna get more than a dollar here, there on the vaccines. You should be Yeah. I don't, yeah, you, you should be measuring, you know, what your vaccine zero profitability is with or without the admin fees. Just so that you have, and then you have to break it down by commercial and Medicaid.

Cause obviously you're not paying for the product on the Medicaid side. 

[00:55:14] Chip Hart: Correct. And, and generally speaking, Suzanne Madden did some really deep research on this and 10 years ago it cost, I she could tell you what the, what she came up with, but the, the Arizona chapter came up with the number.

It was like $11 per administration. That's what it cost in an analysis that they did. And I'm, I'm gonna guess right now with, with wages where they are and additional overhead of giving vaccines than even 10 years ago. I think it's between 15 and 20 bucks to give an administration. That's what you're paying staff largely, of course, that that varies massively with how you delegate your vaccine work.

But let's say it's, let's say it's 15 bucks. Let's say it's 18 bucks per vaccine. Well, there are some times you give, you give a flu shot. You'll be lucky to get 18 bucks for your admin. You give a Penta cell, you're going to get quite a bit more than that. All right? And so it's, you have to look at what you, your broad.

You know, across the board average your stuff because it's not like as pediatricians, you're going to be in the business of giving profitable vaccine lines. Oh. I only give the petta sell and the, whatever the Tdap, I'm making it up. I don't give mm r I don't, I don't, you know, because, because I lose money on it.

That's not, that's, no one does that. It's, 

[00:56:35] Dr. Bravo: it's a bizarre business concept. Well, no, it's not really. Vaccines for a pediatric office are lost leaders. We do it cuz it's the right thing to do. We just hope not to lose 50 or a hundred grand a year vaccinating kids. That's really bottom line.

It's just about minimizing the loss. You know, we, we make more money from the sick visits, you know, as a profit center because there are more of 'em and they're quicker. But, but, you know, we do the vaccines cuz it's the right thing to do. We just have to make sure that we are not losing 5,000 grand, you know, per provider vaccinating.

Cuz that's not sustainable. And that's why no, it's not. 

[00:57:16] Chip Hart: That's why look at, I don't clearly during Covid, all right, COVID was a cash grab for pharma and for the insurance companies. All right. The Covid vaccine comes out and you didn't have to pay for. The product, but you would get 35 bucks to give it.

All right. 40. Now the implication is, oh, well that's $35 profit every time I give it. No, no, no, no, no, no, no, no. Because man, trying to figure out how you were even gonna get paid. All right. Figuring out how to store it. Having to deal with, I mean, having to deal, as some of our clients did, how to deal with protestors out in front of your office.

Right. How to deal with families who left your practice because you're giving the vaccine how to answer, how to answer hours, not just hours, weeks of questions for all your families. There wasn't enough money to do that. Like that's not enough. Like it's in, so on one hand, in some of my clients' bank accounts, there's decent amount of money for giving those covid vaccines.

But no one did it for the money. No one did it for the money. You would never have done it for the money. It's and, and not worth it for 

[00:58:30] Dr. Bravo: the money. No, we didn't really know the answers. Right. You know, talk about scientific method. We were just flying by the seat of our pants. Like, should I vaccinate my kid?

I don't know. I think you should, but I don't know. I mean, I, I don't, vaccines take 20 years to develop. This was developed in nine months, you know, there's tons of studies and safety and what happens to your immunity five years, 10 years after you got the vaccine? We, we have nine months. And little, little tiny studies, and I'm supposed to extrapolate What's gonna happen to your one-year-old once I get the vaccine when he's 25?

I don't know. No one really knows. We're guessing it's gonna be great and it will be great. It's a safe vaccine. But you know, it, it was a very stressful for parents and pediatricians who were actually trying to make the best choice for their kid to keep them safe and not do harm. It it wasn't an easy shot.

No, not, not, not like H P V. I can tell you, I tell people, you are fool if you don't take the H P V, it's a miracle. There's been two miracles. Hepatitis B H P V two cancer preventing vaccines. They're working on the third one in Boston for preventing breast cancer. And you're gonna walk away from that miracle.

You're 

[00:59:52] Chip Hart: dumb. , I read a piece in mm, scientific American, I can't remember where there are three or four dozen cancer vac Mr. mRNA cancer vaccines in trial right now. Yeah. All right. And that, is that gonna be a game changing for breast game 

[01:00:08] Dr. Bravo: changers? Imagine that. They what? Where I can vaccinate a little girl?

And say, you'll ain't going to have to have chemotherapy 

ever in your timeline.

[01:00:17] Chip Hart: Pediatricians are the only specialty that actually fight cancer. Everyone else depends on it for to stay in business. That's right. Period. All right. If we, if pediatricians, if our side of this fence starts giving vaccines that eliminate cancer, the hospitals are going to freak out already.

They're now, all right. What, what other the Well it means, all right, imagine you're the bean counter up at the hospital. All right? Doesn't matter if you're for-profit or not, cuz that for-profit, non-profit designation is all BS as well. Yeah. You're the bean counter up at the hospital and all of a sudden you realize these pediatricians are giving vaccines that are gonna eliminate breast cancer.

You know, right now you have a ticking time bomb. 20 years from now. Yeah. All right. And, and if you, if some of these vaccines come out and can be given to adults All right. About that. This is, this is gonna present prevent carcinoma. This is gonna prevent, I mean, you know, there's a zillion cancers under the sun.

Every one of them that we can prevent at any point is going to subtract billions of dollars from the healthcare industry. Yes. And pediatricians are the only ones who are like, la la, la I'm given the shot because it's the right thing to do. Everyone else, everyone else depends on that revenue and Right.

That's right. It pits you against everyone else. Yeah. And, and by the way, that was my segue herb into your other topics. All right. I think you can, I think you can build a bridge to the other topic.